In some states, there aren't enough doctors to go around.

Where Have All the Doctors Gone?

Tracey Rosato of Fairfield, Connecticut, was elated when her home pregnancy test came out positive. But when she called her ob-gyn of 15 years to schedule her first obstetric (ob) appointment, she was distraught to learn that he was no longer delivering babies. "The nurse told me that because of the rising cost of malpractice insurance, my doctor would be dropping the obstetrics practice and just practicing as a gynecologist," Rosato says. "I was really at a loss."

Finding and keeping an ob-gyn is becoming harder and more complicated for many women. In the past five years, more and more doctors who care for pregnant women have retired early, moved out of state, or simply dropped the practice of delivering babies from their list of services. Is this a crisis? That depends on where you live. In some states, the drop-off in ob numbers is a minor inconvenience, requiring some additional research and hassle. But for other communities, there's a true shortage of ob-gyn care. In 12 states identified by the American Medical Association as being in crisis, 39 percent of ob-gyns surveyed earlier this year were planning to discontinue their obstetrics services. "As that happens, we start to hear the stories: a woman who had to find a new doctor four times during her pregnancy, delays in getting appointments, delays in getting care," says Charles Hammond, MD, a professor of ob-gyn at Duke University and immediate past president of the American College of Obstetrics and Gynecology (ACOG).

How did we get here? A number of factors -- legal, social, and generational -- have converged in the ob-gyn industry to create what one frustrated doctor called a "perfect storm" in the baby business.

Malpractice Insurance is Costly

All doctors must carry malpractice insurance, and the more a class of doctor is likely to get sued, the higher the cost of insurance. The average ob-gyn can expect to get sued 2.5 times in his or her career. Only neurosurgeons get sued more often. As a result, malpractice insurance for ob-gyns has always been pricey. But in recent years, the costs have skyrocketed. Between 1982 and 1998, the national median insurance premium for ob-gyns jumped 167 percent, ACOG says. Last year, rates rose almost 20 percent. Today, nine states, including Florida, Ohio, and Illinois, have insurance premiums in excess of $100,000 a year. (The average base salary for an ob-gyn in 2002 was $248,000.)

Some experts blame frivolous or emotionally charged lawsuits for the rate hikes. Others say the fault lies with the struggling stock market, which is no longer providing insurance companies with a steady income, so they've bumped up their fees to compensate. But whatever the reason, the cost of malpractice insurance is having a direct effect on doctors. Delores Williams, MD, a solo ob-gyn in Trenton, New Jersey, has been delivering babies for 20 years. In July, she gave it up for good because she can't afford her state's malpractice insurance. "I know a physician who borrowed $86,000 this year to pay his insurance bill. I have two children in college. I can't risk losing my home or being unable to pay for their education. I've just resigned myself to the fact that it's time for me to get out." She says she'll keep the gynecology part of her practice open, but it will be a pinch, since her business is now split 50-50 between obstetrics and gynecology patients.

Other doctors are choosing to move their practices to states where the insurance premium is lower. Shelby Wilburn, MD, left Las Vegas, where he had practiced for 12 years, and moved to Belfast, Maine. "When I left, my patients, many of whom had been with me for years, were forced to find another doctor among a dwindling population of ob-gyns," he said in testimony to Congress about the need for tort reform. As Dr. Hammond points out, when ob-gyns leave the state, it doesn't just affect pregnant patients -- there's less access to regular gynecological services such as Pap smears and breast exams.

MDs Are Squeezed by Health Insurance

As insurance rates go up, why can't doctors simply charge more? Today, managed care makes that impossible. As most people know, insurance companies set the rates, and if doctors refuse to accept them, they are dropped from the plan. But in many cases, reimbursements by insurance companies are going down just as costs are going up. That puts the industry in a serious bind. "What other business is forced to operate this way? In any other business, when your expenses go up, you raise your prices. Ob-gyns can't do that," says Edward Dench, MD, head of the Pennsylvania Medical Society.

This situation weighs heavily not just on the doctors currently in practice but on the next generation as well. In 2001, ACOG undertook a survey of doctors-in-training in conjunction with the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Participants were asked to rank reasons they might avoid ob-gyn as a specialty. The results suggested that managed care made potential ob-gyns nervous. They cited long hours and low reimbursement as reasons to stay out. And, says veteran obstetrician Dr. Dench, they're not wrong. "A young doctor coming out of med school with sizable debt and a career choice to make can't help but see that joining an ob-gyn practice doesn't make good business sense," he says.

Crazy Schedules Are an Issue

Surprisingly, though, the uncertain financial picture was not the biggest downside medical students cited about the specialty. Instead, lifestyle issues topped the list of reasons they might avoid going into ob-gyn. "Long, irregular hours," "very demanding," "too much time away from family," and "stressful" were among their comments. Medical malpractice costs were number two on the list. Clearly, the next generation of doctors seems to be more worried about burnout than lawsuits. Few who enter the medical profession expect a cushy existence, but ob-gyns face a particularly grueling schedule. After all, babies come into the world at all times, day and night, which means ob-gyns don't get to set their own hours. "It's pretty tough," says Gary Frishman, MD, associate professor of ob-gyn at Brown Medical School. "The hours are pretty disruptive."

Of course, an unpredictable schedule has always been part of the ob-gyn package. But while older doctors may have accepted the loss of family time their careers demanded, the new crop of physicians is less willing to make those sacrifices. More women are entering the profession, bringing with them their concerns about balancing work and family. And more men are reassessing their priorities, hoping to break the tradition of long hours away from home. Of course, whether these concerns result in fewer doctors choosing to specialize in this field remains to be seen -- bringing babies into the world is a powerful experience, which is why so many doctors seem to love it despite the downsides.

What's Being Done to Address These Problems?

The ob-gyn squeeze has begun to attract attention -- and change.

ACOG maintains that medical liability reform is the answer. The organization has been lobbying Congress to place a $250,000 cap on punitive damages in medical malpractice lawsuits. Some states, such as California, and recently West Virginia, have passed legislation to maintain these caps in local jurisdictions. Pro-tort reform groups say that a cultural trend toward litigation and a willingness by juries to be swayed by hard-luck stories has thrown the economics of malpractice insurance out of whack. "Liability isn't about fault or bad practice anymore. It's about hitting a jackpot. Even the very best ob-gyns have been sued," Dr. Hammond says. "And doctors who have never been sued are seeing their liability premiums double and triple -- not because they're bad docs, but because they practice in a litigation-happy field where everyone is fair game."

Not everyone agrees this is the answer. Patient advocacy groups assert that tort reform unfairly limits the rights of injured patients to seek compensation when doctors make mistakes that cause lasting damage. What's more, the advocacy group Public Citizen charges that the focus on tort reform moves the spotlight away from insurance companies, which ought to be taking more heat for their high rates.

Meanwhile, the medical industry is taking baby steps toward resolving its lifestyle issues. For example, Dr. Frishman says he has noticed a new type of ob-gyn practice emerging -- one that offers physicians the option of working part-time. This modern arrangement will help keep doctors with young families in the ob-gyn fold, he says. "There's no question in my mind that these issues are going to be resolved. It's become such a hot button in so many states," says Dr. Frishman. "It's not a crisis everywhere, but in some places it has reached that point. That has gotten everyone's attention."

Ellen Neuborne, a mother of two, is a writer in New York City.

American Baby